Contrast enhanced ultrasound (CEUS) in Pregnancy: Is this the last frontier for microbubbles?

In this issue a group of researchers present their experience using the ultrasound contrast agent (UCA) SonoVue™ (Bracco SpA, Milan) in a series of pregnant women, assessing and characterising incidental focal liver lesions with magnetic resonance (MR) imaging as the reference standard [1]. The authors have assessed six pregnant women using contrast enhanced ultrasound (CEUS) over a period of time, each with focal liver lesions not characterised on the baseline ultrasound examination, two of which were malignant, and without any recorded detrimental effect to the foetus. The presence of malignancy, unexpected in both cases, substantially altered patient management and confirmation of benign disease allowed for continued normal pregnancy management. The one case of Echinococcal disease maintained a normal pregnancy and delivery, with definitive management instituted post-delivery. All the patients avoided the potential of ionising radiation from a computed tomography (CT) examination, and underwent an MR examination without contrast enhancement (gadolinium). The authors argue that as the UCA is truly intra-vascular the UCA should therefore theoretically be of no hazard to the foetus during a CEUS examination, and this technique should be more widely applied during pregnancy to avoid imaging with MR and potentially CT, both with contrast agents that may have a deleterious effect in the foetus.

• References

• 1 Schwarze V, Marschner C, Negrúo de Figueiredo G. et al. Single-center study: evaluating the diagnostic performance and safety of contrast-enhanced ultrasound (CEUS) in pregnant women to assess hepatic lesions. Ultraschall in Med 2019 Jul 30. doi:10.1055/a-0973-8517 [Epub ahead of print]
• 2 Claudon M, Dietrich CF, Choi BI. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver – update 2012. Ultraschall in Med 2013; 34: 11-29
• 3 Seitz K, Strobel D, Bernatik T. et al. Contrast-enhanced ultrasound (CEUS) for the characterization of focal liver lesions prospective comparison in clinical practice: CEUS vs. CT (DEGUM Multicenter Trial). Ultraschall in Med 2009; 30: 383-389
• 4 Seitz K, Bernatik T, Strobel D. et al. Contrast-enhanced ultrasound (CEUS) for the characterization of focal liver lesions in clinical practice (DEGUM Multicenter Trial): CEUS vs. MRI – a prospective comparison in 269 patients. Ultraschall in Med 2010; 31: 492-499
• 5 Jacob J, Deganello A, Sellars ME. et al. Contrast enhanced ultrasound (CEUS) characterization of grey-scale sonographic indeterminate focal liver lesions in paediatric practice. Ultraschall in Med 2013; 34: 529-540
• 6 Sidhu PS, Cantisani V, Deganello A. et al. Role of contrast-enhanced ultrasound (CEUS) in paediatric practice: An EFSUMB position statement. Ultraschall in Med 2017; 38: 33-43
• 7 Fontanilla T, Minaya J, Cortes C. et al. Acute complicated pyelonephritis: contrast-enhanced ultrasound. Abdom Imaging 2012; 37: 639-646
• 8 Huang DY, Yusuf GT, Daneshi M. et al. Contrast-enhanced US guided Interventions: Improving success rate and avoiding complications using US contrast agents. Radiographics 2017; 37: 652-664
• 9 Liu BX, Huang GL, Xie XH. et al. Contrast-enhanced US-assisted percutaneous nephrostomy: A technique to increase success rate for patients with nondilated renal collecting system. Radiology 2017; 285: 293-301
• 10 Daneshi M, Yusuf GT, Fang C. et al. Contrast-enhanced ultrasound (CEUS) nephrostogram: utility and accuracy as an alternative to fluoroscopic imaging of the urinary tract. Clin Radiol 2019; 74: 167. e9-167
• 11 Sidhu PS, Cantisani V, Dietrich CF. et al. The EFSUMB guidelines and recommendations for the clinical practice of contrast-enhanced ultrasound (CEUS) in non-hepatic applications: Update 2017 (Short Version). Ultraschall in Med 2018; 39: 154-180
• 12 Denbow ML, Blomley MJ, Cosgrove DO. et al. Ultrasound microbubble contrast angiography in monochorionic twin fetuses. Lancet 1997; 349: 773
• 13 Denbow ML, Welsh AW, Taylor MJ. et al. Twin fetuses: intravascular microbubble US contrast agent administration – early experience. Radiology 2000; 214: 724-728
• 14 Liu D, Yang M, Wu Q. Application of ultrasonography in the diagnosis and treatment of cesarean scar pregnancy. Clinica Chimica Acta 2018; 486: 291-297
• 15 Bracco. LUMASON (sulfur hexafluoride lipid-type A microspheres) for injectable suspension, for intravenous use or intravesical use. Full Prescribing Information. Monroe Township, NJ: Bracco Diagnostics Inc., December 2016. https://imaging.bracco.com/sites/braccoimaging.com/files/technica_sheet_pdf/us-en-2017-01-04-spc-lumason.pdf . Accessed December 9, 2019
• 16 European Medicines Agency. SonaVue. Summary of product characteristics, 25 May 2018. https://www.ema.europa.eu/en/documents/product-information/sonovue-epar-product-information_en.pdf . Accessed December 9, 2019
• 17 Hua X, Zhu LP, Li R. et al. Effects of diagnostic contrast-enhanced ultrasound on permeability of placental barrier: A primary study. Placenta 2009; 30: 780-784
• 18 Roberts VHJ, Morgan TK, Bednarek P. et al. Early first trimester uteroplacental flow and the progressive disintegration of spiral artery plugs: new insights from contrast-enhanced ultrasound and tissue histopathology. Hum Reprod 2017; 32: 2382-2393
• 19 Bertholdt C, Eszto ML, Tournier M. et al. Assessment of uteroplacental vascularisation in early first-trimester pregnancy with contrast-enhanced ultrasound and 3D power Doppler angiography: protocol for a prospective, cross-sectional, multicentre and non-randomised open study (“HOPE Study”). BMJ Open 2019; 9: e030353